Is conservative management effective in Emphysematous Pyelonephritis? Vijay Anand, Vineet, Sridharan, Venkat Ramanan, Sunil Shroff, M.G.Rajamanickam. Department of Urology & Renal transplantation, SRMC & RI.

Emphysematous pyelonephritis Acute necrotizing parenchymal and perirenal infection caused by gas forming organisms. High morbidity & poor prognosis. Rate of Nephrectomy: 21-29% Mortality rate: 60-75%

AIM To analyze the efficacy of conservative management in EPN.

Methods Retrospective study Inclusion criteria: All patients of EPN managed in our centre in the last three years. Diagnosis of EPN: Based on clinical and radiological findings The risk factors and classification done based on study by Wan et al * Correlation between imaging finding & clinical outcome ; Liang Wan, Tze u lee ; Radiology 1996; 198: 433-438

Classification according to extent of involvement Class I : Renal pelvis Class II : Renal parenchyma Class III A : Perinephric tissue B : Beyond Gerota’s fascia. Class IV : Bilateral involvement EPN in solitary kidney

Radiological Classification Type I – Parenchymal destruction, absence of fluid collections and presence of mottled gas (Dry type) – Mortality : 69% Type II – Renal or perirenal collections with bubbly or loculated gas or gas in collecting system. (Wet type) Mortality : 18% Wan et al 1996, Best et al 1999

Risk factors Thrombocytopenia Acute renal insufficiency Low S. Albumin Altered mental status Shock on presentation AUA, 2005 More than 2 risk factors – Poorer prognosis

Conservative Management in EPN Antibiotics Supportive measures Stenting / Per-cutaneous drainage Indications Rising S.Creatinine Hydroureteronephrosis Sepsis Significant renal or peri-renal collection (Percutaneous drainage)

Results Total # of patients : 18 Male : Female : 1: 2 (6 M, 12 F) Age : 34-67yrs (mean 51).

Patient categorization Class 1 - 5 patients Class 2 - 4 patients Class 3A - 6 patients Class 3B - 1 patients Class 4 - 2 patients

Class 1

Class 2

Class 3A

Class 3B

Class 3B

Class IV

Class IV

Radiological types Dry Type : 4 Wet Type : 14

Type I - gas radiates diffusely No associated fluid collections are seen Type II - several small foci of gas Associated regions of fluid attenuation.

Risk Factors Low S. Albumin – 18 Acute renal insufficiency : 16 Thrombocytopenia: 11 Altered mental status - 3 Shock on presentation - 2

Co-existing Diabetes Mellitus No. of pts with DM: 18 Established DM 16 Incidentally diagnosed 2 Hb A1c raised ( mean – 12.2)

Causative organisms Klebsiella : 2 Citrobacter : 1 No growth : 3 Esch. coli : 12 Klebsiella : 2 Citrobacter : 1 No growth : 3

Management DJ Stenting – 11 DJ Stent+Percutaneous drainage – 3 Nephrectomy - 1

Pre and Post Stenting

Pre & post per cutaneous drainage

Management vs Class of EPN 1 2 3A 3B 4 DJ STENT 5 DJ STENT + PCD PCD only NEPHRECTOMY

Management & Class of EPN

Management vs Number of Risk factors 1 2 3 4 5 DJ STENT 7 DJ STENT + PCD PCD NEPHRECTOMY

Mortality - 1 Class 3B Radiological type – I Number of risk factors – 5 Outcome – expired within few hours

Effectiveness of Conservative management Risk factor > 2 - 9/16 patients Patients with class 3A, 3B, 4 – 7/16 patients

Follow up Follow up – 3 months to 24 months Mean – 6 months Recurrent EPN @ 3months - 1 Pyelonephritis (Non emphysematous) - 1

Conclusion Conservative management is a safe, effective and feasible treatment option in patients with Emphysematous pyelonephritis.

Thank you